Provider Demographics
NPI:1811259898
Name:LUI, KIRSTEN (DMD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:LUI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 REVERE BEACH PKWY APT 710
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5164
Mailing Address - Country:US
Mailing Address - Phone:617-855-5477
Mailing Address - Fax:
Practice Address - Street 1:520 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452
Practice Address - Country:US
Practice Address - Phone:781-216-8097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18560081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice